Provider Demographics
NPI:1366692246
Name:DIANA M MANCUSO MD PA
Entity Type:Organization
Organization Name:DIANA M MANCUSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-4120
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 16
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-4120
Mailing Address - Fax:334-615-8443
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 16
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-4120
Practice Address - Fax:334-615-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000000013OtherMEDICARE PROVIDER NUMBER
AL000000013Medicaid
AL000000013Medicaid
ALC72543Medicare UPIN